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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602556
Report Date: 12/12/2023
Date Signed: 12/12/2023 11:40:27 AM

Document Has Been Signed on 12/12/2023 11:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PDM-HORSTFACILITY NUMBER:
198602556
ADMINISTRATOR:LOPEZ, ARCHIMEDES CFACILITY TYPE:
735
ADDRESS:18318 HORST AVETELEPHONE:
(562) 552-5579
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 4CENSUS: 1DATE:
12/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:TIME COMPLETED:
11:45 AM
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LPA Ashley Calderon visited the facility for an unannounced 1 year required annual inspection.LPA upon arrival met caregiver, Jennifer Ong. Shortly after LPA met with Administrator Archimedes "Archi" Lopez and Assistant Administrator Mirafy Lopez and discussed the purposed for the visit.

The facility has an Adult Residential Facility licensed to serve a total of four (4) non ambulatory developmentally disabled adults between the ages of 18-59, one (1) can be bedridden. This facility is approved for one (1) hospice waiver.

Currently there is (1) client in place. Clients are placed through vendorized agency: Harbor Regional Center.
LPA Calderon used CARE inspection tool to conduct the visit and conducted staff interviews and client interview attempt. The facility is a single story facility containing: living room, kitchen, dining room, four bedrooms, (no staff bedroom), two bathrooms, laundry area (in garage) , backyard patio and a attached two car garage,

The following was observed, reviewed and inspected:
  • LPA requested, received and reviewed (1) client medications with Medication Administration Record (MAR), all medications have labels and physician's orders, all medication were noted on the MAR. LPA requested, received and reviewed the client files, all client files contained the required documents including: IPP, Face Sheet/Identification Page, Physician's Reports with TB Test Results. LPA requested, received and reviewed (4) staff files, all staff files contained the required documents including: Health Screening with TB Test Results, First Aid and all staff were clear.
  • LPA alongside with Administrator toured and inspected the physical plant:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PDM-HORST
FACILITY NUMBER: 198602556
VISIT DATE: 12/12/2023
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  • Kitchen: refrigerator, freezer, microwave and counter tops were clean, ample supply of perishable and nonperishable foods for client in care.

  • All sharp objects, toxins, medications and client records were locked and inaccessible to clients in care, the required amount of dishes, utensils, plates, cups and glasses for the current census were available.

  • Bedrooms: all bedrooms contain the required furniture, lighting fixtures, mattresses. Beds contain the required amount of linen.
  • Hallways: all hallways are free of obstructions, walls, ceiling and floor are if good repair.

  • Smoke detectors tested and functioning hardwired with carbon monoxide detector also tested and functioning. Telephone on premises.

  • Bathrooms: shower, toilets and face bowls operational, nonskid mates and grab bars observed.

  • Garage: organized and kept locked. Hygiene products observed.

  • Yards: front and back yards are well maintained and free of debris, patio area with chairs and shade, no large bodies of water observed.

Facility has First Aid Kit in place.

Administration Expires:June 3, 2025

Last Fire Drill Date conducted on:12/8/23, drills are conducted every (3) months.

No Deficiencies cited under California Code of Regulations Title 22.

Exit Interview Conducted and a copy of report will be provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC809 (FAS) - (06/04)
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